T&NMHO UPDATE
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Volume XII, Issue 22
Serving the Hospices of New Mexico & Texas
February 16, 2016
T&NMHO CALENDAR
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09/12/08
T&NMHO Board of Directors
Meeting, THA Building, Austin, TX, 9 am.
12/12/08
T&NMHO Board of Directors
Meeting, Online, 10 am.
05/01-03/09 T&NMHO’s 27th Annual Conference,
Wyndham Greenspoint Hotel, Houston
04/09-11/2010 T&NMHO’s 28th Annual
Conference, Omni San Antonio Hotel at the
Colonnade, San Antonio
03/19-21/2011 T&NMHO’s 29th Annual Conference
Omni Mandalay Hotel at Las Colinas, Dallas
03/16-18/2012 T&NMHO’s 30th Annual
Conference, La Fonda Hotel, Santa Fe
03/15-17/2013 T&NMHO’s 31st Annual
Conference, Omni Houston
END-OF-LIFE CHEMOTHERAPY
“The Role of Chemotherapy at the End of Life,” in the
June 11 JAMA, says, “Patients face difficult decisions
about chemotherapy near the end of life. Such treatment
might prolong survival or reduce symptoms but cause
adverse effects, prevent the patient from engaging in
meaningful life review and preparing for death, and
preclude entry into hospice. Palliative care and oncology
clinicians should be logical partners in caring for patients
with serious cancers for which symptom control,
medically appropriate goal setting, and communication
are paramount, but some studies have shown limited
cooperation.”
The authors say that it is important to identify the goals
of chemotherapy and to know who is likely to benefit
from chemotherapy in the late stages of a disease.
“Patients are unlikely to benefit from chemotherapy when
they have already been failed by the standard regimens,
have poor performance status, and otherwise have a poor
prognosis.” The authors note that there are other reasons
for not choosing chemo at the end of life. Among them
are the negative side-effects, the fact that it may prevent
patients from entering hospice, the costs and lost
opportunities for preparing for a peaceful death.
The article suggests that physicians need more honest
communication with patients, and includes a sidebar of
“Things to Do or Say (and Not to Do or Say) About
Chemotherapy for Advanced Cancer.” Other suggestions
include bringing up hospice soon enough for it to be part
of the standard cancer care, not just a few days or weeks
before death, and asking people what they want to know
and then giving them that information.
Another sidebar to the article contains a list of questions
that patients need to ask about palliative chemotherapy.
Questions to ask about treatment include: “What is my
chance of cure? What is the chance that this
chemotherapy will make my cancer shrink? Stay stable?
Grow? If I cannot be cured, will I live longer with
chemotherapy? How much longer? What are the main
side effects of the chemotherapy? Will I feel better or
worse? Are there other options, such as hospice or
palliative care? How do other people make these
decisions? Are there clinical trials available? What are
the benefits? Am I eligible? What is needed to enroll?”
The questions suggested for prognosis are: “What are the
likely things that will happen to me? How long will I
live? (Ask for a range, and the most likely scenario for
the period ahead, and when death might be expected.)
Are there other things I should be doing? Will?
Advance directives? Durable power of attorney for
health care who can speak for me, if I am unable?
Financial or family legal issues? Durable power of
attorney for financial affairs? Trust?”
On family issues, patients should ask if the physician will
help them talk to their children. They should ask who is
available to help cope with spiritual and psychological
issues. And, lastly, they should ask, “What do I want to
pass on to my family to tell them about my life?”
In conclusion, the authors say, “The conundrum for
today’s oncologist is that moving on to third- or fourthline chemotherapy may be easier than discussing hospice
care, the patient and family may be less upset, and they
may prefer to not discuss the issue with the oncologist.
Adverse effects of chemotherapy may be minimal,
discussions take more time, and chemotherapy
intervention is better compensated than are discussions.
However, without a clear goals-of-care discussion,
patients … and families may be unprepared for what the
final few months, weeks, or even days may bring.
Through honest and respectful communication about the
last stages of cancer, physicians can give patients a
genuine choice about how to spend their last phase of
life.” (JAMA, 2008;299(22):2667-2678; Newswise,
6/11)
CANCER DOCTORS AVOID “THE BIG TALK”
A recent AP article, which appeared in a number of
newspapers last week, examines the reluctance of doctors
to tell patients with cancer that further treatment is futile.
But a new study of “what happens to patients if they are
or are not asked what kind of care they'd like to receive if
they were dying” says that the perception of doctors who
think they’re doing patients a favor by failing to talk
about ending active treatment in the belief that they are
“keeping hope alive” is wrong.
The study of 603 patients who had failed chemotherapy
and were expected to live for less than a year found only
one-third of them had physicians who discussed end-oflife care with them. But those patients were “no more
likely to become depressed than those who did not, …
were less likely to spend their final days in hospitals,
tethered to machines, … avoided costly, futile care, [and]
their loved ones were more at peace after they died.”
Barbara Coombs Lee, president of Compassionate
Choices, says, “Boiled down, it’s ‘Talking about dying
will kill you.’” Instead, she says, “People crave these
conversations, because without a full and candid
discussion of what they're up against and what their
options are, they feel abandoned and forlorn, as though
they have to face this alone. No one is willing to talk
about it.”
number of problems with the current system.
Among them, he says, are “an erosion of
relationships between primary-care physicians and
patients, an over-reliance on medical procedures and
technology, and the submission of medical judgment
to patients’ desires.” Fisher says, “Patients who
have no chance of survival are subjected to
unnecessary tests, treatments and procedures, …
[which] undermines their humanity and the humanity
of the doctors providing this kind of care.”
(Newhouse News Service, 6/13)
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PUBLIC POLICY NOTES
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A GAO probe has found that 27,000 health care
providers who accept Medicare payments owe more
than $2 billion in unpaid federal taxes, and calls its
own numbers “substantially understated” because
many Medicare providers were not included.
Congress wants CMS to use the Federal Payment
Levy Program, which lets the IRS “withhold
government payments to contractors that owe taxes.”
Beginning in October, Medicare officials will
“subject 60% of Medicare fee-for-service payments
to IRS scrutiny for tax delinquencies,” and will
“exchange Medicare payment information with the
Treasury Department every day.” (The Wall Street
Journal, 6/20; USA Today, 6/20; The Washington
Post, 6/20)
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Hospices are generally pleased with the new CoPs.
Attorney Mary Michal says, “The CoPs … will
require that hospices engage in considerable
compliance efforts, [but] overall they contain a
strong emphasis on promoting quality patient care.”
Judi Lund Person, of NHPCO, adds, “We were
pleased that many of the suggestions made by [the
National Hospice and Palliative Care Organization]
during the public comment period for the proposed
rule were incorporated into the final rule.” (Eli’s
Home Care Week, 6/16)
In the study, about seven percent of all patients studied
experienced depression, but “feeling nervous or worried
was no more common among those who had end-of-life
talks than those who did not.” Dr. John Marshall, at
Georgetown University's Lombardi Comprehensive
Cancer Center, said that patients are often relieved when
an end-of-life discussion is held, and can start making
plans for a “good death.” “It’s sad, and it’s not good
news, but you can see the tension begin to fall," and
patients and families can start planning for a situation
“they may have suspected but were afraid to bring up.”
Dr. James Vredenburgh, of Duke University, is a brain
tumor specialist. He cautions that people are different.
“There are patients who want to talk about death and
dying when I first meet them, before I ever treat them.
There's other people who never will talk about it,”
Vredenburgh said. (AP, 6/15)
RESEARCH & RESOURCE NOTES
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“Patients dying with dementia: experience at the end
of life and impact of hospice care,” in the current
Journal of Pain & Symptom Management, reports on
an evaluation of “the impact hospice enrollment has
on the terminal care of patients with dementia” and
describes the “symptom burden” of the patients.
According to the lead author, the study suggests that
“dying patients with dementia who are enrolled in
hospice programs are more likely to die in their
locations of choice and their caregivers are more
likely to perceive that care is excellent or good than
those who do not obtain hospice services.”
(Hospital Business Week, 6/22)
Dr. Kenneth Fisher, author of In Defiance of Death:
Exposing the Real Costs of End-of-Life Care, cites a
CMS has set the hospice cap for this year at
$22,386.15, and has released it at this time so that
hospices can work with their budgets. The
methodology for computing the cap can be found at
www.cms.hhs.gov/hospice/downloads/2008_Aggreg
ate_Cap_ Amount.pdf. (Eli’s Home Care Week,
6/16)
OTHER NOTES
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In Okeechobee, Florida, Karen Weber’s husband and
family disagree on whether her feeding tube should
be removed. Weber has had a stroke which left her
paralyzed on one side and unable to speak, but she is
not in a vegetative state and can communicate. Her
husband wants her enrolled in hospice, but her
mother disagrees. An injunction is in force until the
judge can decide whether Weber can decide for
herself, and he has appointed a guardian for her, as
well as appointed a committee of psychologists and
neurologists to give their opinions. Weber has no
advance directive, healthcare proxy or living will.
(Palm Beach Post, 6/15)
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Ken Dychtwald is president and CEO of Age Wave,
which “advises businesses and governments on
everything from the changing health care needs of an
aging population to automobile interiors designed
for older drivers.” He has written Age Power, which
“explores the impact that the retirement and aging of
baby boomers will have in coming decades.” He
will be a keynote speaker at the Health Forum–
American Hospital Association Leadership Summit
in San Diego in July. (Hospitals and Health
Networks, 5/2008)
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In The New York Times, health writer Jane E. Brody
writes of controllable cancers that are now chronic
diseases, not death sentences. Dr. Michael Fisch, of
Houston’s MD Anderson Cancer Center, says,
“We’re seeing people being periodically treated and
living year after year with advanced disease, with
cancers that have spread to the lung, liver, brain or
bone. In 1997, we wouldn’t have guessed this would
be possible.” (The New York Times, 6/17)
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In honor of the 25th anniversary of its hospice
program, the Visiting Nurse Service of New York
(VNSNY)sponsored a student film contest in which
hospice patients in the VNSNY Living History
Project were matched with student filmmakers to
create “portraits of lives well lived.” To view the
films, click on the VNSNY link at
www.independentfeatures.com. (Life Science
Weekly, 6/17)
Glatfelter Insurance Group is the national sponsor of
Hospice News Network for 2008. Glatfelter Insurance Group
provides property and liability insurance for hospices and
home healthcare agencies through their Hospice and
Community Care Insurance Services division. Ask your
insurance agent to visit their website at www.hccis.com.